Deciding which code to use starts with determining each payer’s policy.
The Healthcare Common Procedure Coding System (HCPCS) has two principal subsystems, referred to as Level I and Level II. Knowing when to use HCPCS Level I codes versus HCPCS Level II codes can be confusing, mainly because many services are described by both code sets. Knowing which code set to use when is imperative for claims payment. To help you with that, let’s look at a couple of scenarios where there is an exact duplicate of a CPT® (HCPCS Level I) and HCPCS Level II code or a similar code.
Example 1: Preparation of Fecal Microbiota
Our first set of similar codes is CPT® 44705 Preparation of fecal microbiota for instillation, including assessment of donor specimen and HCPCS Level II G0455 Preparation with instillation of fecal microbiota by any method, including assessment of donor specimen.
According to the American Gastroenterological Association, unless otherwise specified by the payer, preparation of a donor specimen is typically covered by the recipient patient’s insurance. The instillation of microbiota is separately reported. When an enema or a nasogastric (NG) or orogastric (OG) tube is used for the instillation, use 44799. For instillation via esophagogastroduodenoscopy (EGD) or colonoscopy, use the appropriate CPT® code for upper gastrointestinal endoscopy or colonoscopy.
Medicare created their own code, G0455, to identify the work of preparation AND instillation of the microbiota. Medicare does not pay a separate fee for the instillation of the microbiota by orogastric tube, nasogastric tube, enema, or upper or lower endoscopy.
Example 2: Vaccine Administration
There are several different codes for vaccine administration. When choosing a vaccine administration code, you will typically need to know the:
Payer;
Vaccine being administered;
Route of administration; and
Age of the patient (if counseling is provided).
Let’s focus on differentiating the following codes:
90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid);
90472 each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)
G0008 Administration of influenza virus vaccine
G0009 Administration of pneumococcal vaccine
G0010 Administration of hepatitis B vaccine
Medicare created three vaccination codes, each specifying the pathogen being targeted — specifically, administration of the flu vaccine, pneumococcal vaccine, and hepatitis B vaccine. When billing Medicare, you are required to use the G codes instead of 90471. While each vaccination has a unique code with Medicare, other insurance companies generally require the use of both 90471 and 90472 when multiple vaccines are administered on the same day.
For example, if both the flu and pneumococcal vaccines are administered on the same day, you would report the administration to Medicare using codes G0008 and G0009. For commercial insurance, however, you would use 90471 and 90472.
Example 3: Prolonged Services
Next, let’s examine the following two codes for prolonged services:
+99417 Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes of total time (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)
G2212 Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to cpt codes 99205, 99215 for office or other outpatient evaluation and management services) (do not report g2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416). (do not report g2212 for any time unit less than 15 minutes)
CMS accepted the 2021 AMA changes to office and other outpatient codes 99202-99215, but CMS elected not to accept CPT® code +99417. Instead, CMS created G2212 for prolonged services for office and other outpatient evaluation and management (E/M) services. You cannot use a system crosswalk to convert CPT® code +99417 to HCPCS Level II code G2212 based on the patient’s insurance. While both codes are used in addition to either 99205 or 99215 and allow for a total of 15-minute time increments in full, +99417 is calculated off the minimum time requirement of 99205 or 99215, while G2212 is calculated from the maximum time requirement. Therefore, a direct one-to-one crosswalk will not work.
For example, if a provider spends a total time 60 minutes on the date of service for an established patient, they would bill the insurance company using E/M codes 99215 and +99417. CPT® code 99215 has a time range of 40-54 minutes. Calculating 15 minutes above 40 minutes allows you to bill +99417 once 55 minutes has been reached. Since we only have an additional five minutes above the 55 minutes, that supports reporting 99215 and +99417. You cannot bill for an additional unit of +99417 because a total of 30 minutes above the minimum time has not been met.
Let’s apply this example to a Medicare patient. Since the maximum time for 99215 is 54 minutes, the provider must spend 69 minutes with the patient before you can bill G2212 in addition to 99215. You would not want to set up a crosswalk in your system because the requirement for G2212 has not been satisfied.
Details Matter
As with everything coding related, you must know your target audience, specifically the insurance company, along with their policies, to ensure correct coding and billing. You must always read the documentation to ensure it supports the coding. There is not a direct one-to-one relationship between all CPT® and HCPCS Level II codes; if audited, using a crosswalk may put your practice at risk for adverse findings. Remember, just because you receive payment when you bill for a service does not mean the practice gets to keep the money.
What Is HCPCS?
HCPCS Level I comprises the Current Procedural Terminology (CPT®-4) code set, a numeric coding system maintained by the American Medical Association (AMA), used to submit medical claims to payers for procedures and services performed by a qualified healthcare professional. Many coders do not realize that CPT® codes are HCPCS Level I codes. If you see an edit in your claims edit system asking you to verify the HCPCS code, it may be asking for clarification on either a HCPCS Level I (CPT®) or HCPCS Level II code.
HCPCS Level II is a standardized alphanumeric coding system maintained by the Centers for Medicare & Medicaid Services (CMS), used primarily to identify medical devices, supplies, medications, and other items and services not included in the CPT® code set. This includes ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). “Because Medicare and other insurers cover a variety of services, supplies, and equipment that are not identified by CPT® codes, the HCPCS Level II codes were established for submitting claims for these items,” explains CMS.
When deciding between a CPT® code and HCPCS Level II code, it is important to know to which insurance company you will be sending the claim and if they follow CMS’ rules for billing HCPCS Level II and CPT® codes. Unfortunately, in medical coding, there is not always a one-size-fits-all solution.
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